What Do Physical Therapists Do? Installment #6: We Critically Appraise Research

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I'm long overdue for another installment of my "What Do Physical Therapists Do?" series.  I've previously written about the PT role in emergency response, return to sport participation, strength training, therapeutic alliance and listening, and assess biomechanics.

Have you ever seen a toothpaste commercial saying "100% of Dentists Recommend that particular brand?"  Do you think to yourself, 1) "Ooohh, I should go buy that right now!?"  Do you wonder, 2) "Would I like that flavor?"  Do you consider,  3) "I wonder if they surveyed one dentist or 1,000 dentists to get that outcome?"  Or do you 4) just let the commercial come and go and ignore it entirely?

I'm very particular when it comes to all things related to teeth... I hate when people walk around brushing their teeth, I can't stand the sound of the electric tooth brush, I gag in response to watching others floss in my presence. I can't understand why they made cinnamon or grape or bubble gum flavored toothpaste when it's clearly meant to be mint-flavored. Only. And chocolate with mint has been ruined.  Tragedy.  Today I'm giving these commercials more thought than they deserve.

I think that many people probably just follow option 4, completely ignoring the commercial and moving on with their show.  But that path ignores that behind that advertisement, there was some amount of research done, data was compiled, and the information was put out into the world for you to interpret.  So the purpose of this blog post is really about choice number 3) "I wonder if they surveyed one dentist or 1,000 dentists to get that outcome."  This isn't where my mind automatically goes, but it's the way that scientific research needs to be considered.  And it makes me nervous to think that there are physical therapists who don't read any research at all - or who read a paper but then ignore the findings entirely.  Just like option 4. 

Let's say you're a physical therapist and you're working with a patient who recently sprained their ankle.  What does the research say is the best thing to do for this patient?  Did one physical therapist present a case study that you read and you're taking their word for the best approach?  Have you, yourself, done a treatment with a similar patient before and found that it worked so you now think it's the best option for everyone with this condition?  Is there a journal article that says to do certain things, but other papers that show the opposite information?  Were the research tests done on a teenage male, like the patient you're working with, or were they conducted on a group of women in their 40's... and does that matter?  These are just the beginning of the thoughts involved in using Evidence-Based Practice in medical care and show why this is so complicated.  What does the research say?  What does it actually mean?  Is it clinically relevant to your patient? 

I've previously written about the changes that healthcare is experiencing here, but in that post, I didn't give enough credit to the transition in healthcare to more use of evidence-based practice.  I think use of research to support the decisions made with patients is very important, but I also find it to be incredibly difficult.  The example above with the patient with the ankle sprain is just one possible scenario out of tons of different ones to see in the clinic.  There isn't research to support all of our decisions, and even if there was research covering all aspects, there's no way I could ever read it all.

For myself, I work in pediatric orthopedics.  In a typical day, I will see eleven patients.  No two are the same, even if three of them are recovering from ankle sprains.  My job limits me to seeing patients between ages 5-21, which is far more restrictive than most people who work in an orthopedics setting.  But research on kids is often lacking, so to try to make decisions for kids based on research in adults tends to happen a lot.  I know that it may not be accurate - but I also know that I don't have anything else to base my decisions on.  While there is an increase in research available for teenagers with ACL tears, there are many conditions and treatment approaches that have not been well studied with matching characteristics to my patients.  And, again, even if I had all the time in the world and devoted it to reading, I could never read all the papers and really know what all the researchers recommend to make the most educated decisions possible.  So we work to make our best decision and review the literature as much as possible, and this requires the ability to critically appraise the literature.  Reading the papers is only the first step.  Understanding their meaning is even more complicated.

I mentioned in my last blog post (here) that I recently launched the Seattle Children's Hospital Sports Physical Therapy Journal Club.  So far, this project is in its infancy.  To get it started, I was advised by several physical therapists working elsewhere who already participate in a journal club to start by focusing on papers that help you critically appraise literature.  I followed their advice, but had to start with learning more about what that even meant. 

Journal of Sports Physical Therapy

According to the Center for Evidence Based Management, "Critical appraisal is the process of carefully and systematically assessing the outcome of scientific research (evidence) to judge its trustworthiness, value and relevance in a particular context. Critical appraisal looks at the way a study is conducted and examines factors such as internal validity, generalizability and relevance."  The Journal of Sports Physical Therapy (JOSPT) has been publishing a series of articles to help Critically Appraise Scientific papers here and as I've been reading through them and collecting information for the journal club, I've been finding that 1) the topic of critical appraisal of the literature is not very interesting, and as such, I have never previously given it much consideration to learn as a skill and better question the research I'm reading. Lack of interest is a poor excuse for something this important.  I'm also not interested in gymnastics, but I work with gymnasts so I need to take an interest in it to sufficiently work with that patient population. 2) There are a whole lot of ways for a scientific study to go wrong - without the researchers having that intent or despite their efforts to avoid it.  Things like bias, blinding study participants, misunderstanding confounding variables or inclusion and exclusion criteria for subjects, insufficient sample size, improper use of certain types of statistics, lack of awareness to the true definition of terms and what they mean in a scientific setting, and I'm sure more ways that I don't even know yet. 3) Research is super complicated and cannot be taken solely at face value.  Simply reading an abstract and the conclusions of a paper can be incredibly misleading if authors have put a spin on their findings or if the methods of the paper are ignored.  Critical Appraisal requires thought, analysis, interpretation, and questioning.  

As clinicians, I think learning about how to appraise the literature is something many of us need to do better.  As physical therapists, many of us did not have to go through the full research process to get to our clinical status.  This may be a shortcoming of our learning because too many of us are not considering whether or not the findings of a study really mean what is presented and whether or not a lab study actually applies to the clinical setting.   It seems like a lot of research principles come from the pharmaceutical world.  If a medication is provided to 100 people and nobody dies and an abstract for the paper says it saves lives, that is a misrepresentation of data.  What if the methods show that the criteria to select the participants in the study excluded people who would really need that medicine?  What if they only tested the medicine on people over age 75 and you work with children - would it also save them?  What if, when the study is expanded further to maybe 1,000 people, there are deaths in the bigger group?  This is a call for us all to be better about consideration of the research with a healthy skepticism towards methodology and interpretation.  

So the next time you want to do a treatment technique on a patient, have you considered the literature supporting or refuting the efficacy of that approach? This could be anything.  Dry needling.  Massage.  Cupping.  Specific types of exercise - maybe yoga or pilates.  Stretching.  Strength training.  Breathing.  Biofeedback. Foam rolling. Desensitization.  We have a lot of tools available to us - many with different levels of support in the literature. And have you looked to see if there is a paper that suggests outcomes to the contrary?  What do you think is the best option for this specific patient?  I'm struggling so much to read papers that, for example, suggest that manual therapy is no better than exercise.  Some patients really do seem to need manual therapy.  There are lots of papers that suggest it isn't useful, and there are also whole institutes, like the North American Institute of Orthopedic Manual Therapy (NAIOMT), who have evidence to support the exact opposite. A paper cannot study every circumstance, so the setting and the patient demographics and pathological condition have to be considered. 

I'm hoping this post just encourages you to question how you use research and evidence-based practice, which you should definitely be doing, and perhaps you can teach me ways to more critically appraise what I'm reading.  We can all get better at doing this.  And we can all hold each other accountable to be better clinicians.